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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
p ,Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ri*rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
0 C-42 0111199
�Date'?�O Signature of Contractor � ��r��� �U)c V �`f �"� 11
OWNER -BUILDER DECCARATIt�e c
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
STA,TF F(JND ON6_9840(3ttiW9
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compe.sation provisions of Section 3700 of the Labor
Code I shall forthwith complyith those provislo, s
pate: !-4 - 7? " APPlicanttate//-``ti.i`,
Warning: Failure to secure Workers' C6m1reensation coverage is unlawful and
shall subject an employer to criminal p1nalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. , / �j�
/gnature (Owner/Agent)jA �p-^-��f`� t'•%""r~ Date
;3.
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT 5113(1-x-030 TRACT 8775
413/914 S11.1100.00
JOB SITE
RPN
ADDRESS
S4-045 AVENIDA CARRANZA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
E.LISEo SIMNTAL
ECONO SE%'ER SERVICE
540.45 A VENIDA CA.RRAN7.A
P.O. BOX 19:
LA QUWTA CA 92353
PALM DESERT CA 92261
(`760)346-2793 C13L# 342
USE OF PERMIT
D1 10.411
PAID
8V %%R CON�il MSEPTIC ABANDOW,11Ti'f
APR 0 3 1998
CITY OF
L�k QUIN TA
CON11WT AMOUNT 1,500.00 I'S
J1.
ESTIMATE0 COST OF CONSTRUCTION
I�St1fl.fiil
PERMIT IEEE SUMMARY
PL.L.INIRINa FET -- SE%111 101-000-419-000 Sau.lx►
SUB -TOTAL CON911Z IC 1ON AND PIAN CHECK
LESS PILE -PAID MELS
$0.00
TOTAT, PEMITT FEES DUE NOW
530.00
f
i
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
' PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral�e
Pool Cover
Sewer Connection /t 7
Encapsulation
Gas Piping
Gas Test
Appliances
9
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
0 Backflow(s)
0 HouseLateral(s)
0 Detector Check(s)
0 Mater Surcharge
4as
KSanitation Capacity Charge
0 W.S.B.RC.
0. Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee -Tract -
Fee -
0 'Plan Check Fees Water! Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
V+LL_
G.A. Code
ECONO SEWER SERVICES
P.O. Box 192
• PALM DESERT, CA 92261
.Phone 328-7760 346-2703
jam 0M 00000
DESCRIPTION OF WORK:
PLEASE PAY FROM. THIS INVOICE
TOTAL MATERIALS
-UATff757rbFZDER
,
,./
NO STATE ENT WILL BE MAILED
a �%
CUSTOMER'S ORDER NO.
PHONE
TOTAL AMOUNT
MECH
HELPER
STARTING DATE
i
I
BILL TO
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ORDER TAKEN BY
ADDRESS
I
DAY WORK
Q
,
CONTRACT
CIT
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EXTRA
JOB NAME AND LOCATION
JOB PHONE
DESCRIPTION OF WORK:
PLEASE PAY FROM. THIS INVOICE
����
� o one home al amount due billing to
Signature for for above work: be m or be mailed after
completion
I hereby acknowledge the satisfactory completion I* of work
of the above described work
TOTAL MATERIALS
TOTAL LABOR
NO STATE ENT WILL BE MAILED
TAX
DATEOMPL ED /f WORK D RED BY
Y
TOTAL AMOUNT
$
����
� o one home al amount due billing to
Signature for for above work: be m or be mailed after
completion
I hereby acknowledge the satisfactory completion I* of work
of the above described work